Jordan University of Science & Technology

Faculty of Nursing
NUR 344
Daily Documentation Sheet
Second Semester 2020/2021
Student Name:‫حامد ماجد الثويني‬
ID#:130218Unit:------------------------------------------------------------------------

Client Name: Haneen Medical Diagnosis:- Abortion

Age:24

Obstetric History :

LMP 28-12-2020 EDD 5-10-2021

GTPAL
3-1-0-2-1
Chief complain on admission:

Pt said " I have heavy vaginal bleeding accompanied with abdominal pain like
contraction since one hour of admission"

NURSING PROCESS

Subjective Data:

Pt said
"I have abdominal pain (6 on scale intermittent)"

I didn’t sleep well last night because of pain and hospital environment"

"I feel bad because I lost the fetus and this is the second time "

"" I want to know about the causes make me not being able to continue pregnancy
for the second time"
"I go to bathroom every three hours about 200 ml each time without any problem "

"I drink about 4 glasses of water and 2 glasses of juice last 24 h "

"I feel dizziness and shortness of breath during walking "

Objective Data:

pale, look sad and tired.

-PE
Abdomen: old stria, bowel sound is 7 gurgle/min

Extremities is cold, capillary refill is more than 3 seconds

Vaginal bleeding bright red color with clot 10cm on bad

Cervix is open.
-LAB
Hb 8 g/dl

HCt 24%,

RBC, 3400

HCG 50 mlU/ml

Vital signs: Temp 37, P 110b/m, Bp 85/60 mmhg, RR 23

Medication
1-Ferrous gluconate(

IRON supplements.
SIDE EFFECTS: bright red blood in your stools. black or tarry stools. Fever.
stomach pain. coughing up blood or vomit that looks like coffee grounds. pain in
your chest or throat when swallowing

ACTION: Iron is necessary for the production of hemoglobin. Iron-deficiency can lead
to decreased production of hemoglobin and a microcytic, hypochromic anemia

Indication: Used in preventing and treating iron-deficiency anemia.

2-Rho(D)immune globulin

Polyclonal antibody

SIDE EFFECTS: nausea, diarrhea, vomiting, stomach pain. headache, dizziness.

drowsiness, weakness, general ill feeling. joint or muscle pain. mild itching or skin
rash. increased sweating. pain or tenderness where the medicine was injected

ACTION: unclear. It is suggested that Rho immune globulin predominantly prevents

the antibody response during incompatible pregnancy by accelerating the
phagocytosis of RBC's and clearance from the circulation before the recognition by
the immune system

Indication: Indicated for suppression of rhesus (Rh) isoimmunization

in nonsensitized Rho (D)-negative women with an Rh-incompatible
pregnancy, or in Rho (D)-negative individuals transfused with
Rh0(D)-positive red blood cells (RBCs) or blood components
containing Rh0(D)-positive RBCs. Also indicated in Rh0(D)-positive,
non-splenectomized adult patients with chronic immune
thrombocytopenic purpura (ITP) to raise platelet counts.

Nursing Diagnosis list :

1-fluid volum deficit RT vaginal bleeding AMP lab result and BP .

2-ineffective tissue perfusion RT DECREASE blood volume AMB physical
examination (BP. capillary refill. COLD Extremities)

3-pain RT PREMATURE CONTRACTION OF THE UTERUS AMB pt verbalization

4-sleep deprivation

5-grief RT loss of previous pregnancy AMB pt verbalization

6-rediness for enhance knowledge about causes of not being able to continue
pregnancy for the second time

7-risk for maternal injury

8-risk for fetal injury

Planning:( Only for the two-priority nursing diagnosis)

- To correct fluid volume

- Pt will show hiding of signs and symptoms of hypovolemia (decrease in blood pressure , RBC's
,and HB) at the end of my shift .

-to enhance tissue perfusion

-pt will show signs and symptoms of good perfusion (warm extremities , present peripheral pulse ,and o2
sat level within normal ), at the end of my shift .

Intervention:(for the two priority nursing diagnoses)

 1- Administer intravenous fluid therapy as prescribed; monitor fluid
replacement levels closely to ensure patient does not experience
fluid overload(increase blood volume )

b- Administer blood transfusion products as prescribed(increase

HB.RBC)

c- Monitor skin turgor and moisture of mucous membranes(because

they are indicator of dehydration which is one of fluid deficit
symptoms)
d- Monitor vital signs (blood pressure and heart rate) (dec BP and
increase HR is indication of blood volume deficit ),

2- Evaluate involved extremity for clinical signs (pain, decreased

temperature, pallor, delayed capillary refill, weak or absent pulse,
decreased sensation, and decreased pulse oximetry) that are
indicators of ineffective peripheral perfusion
.
b- Instruct patient to increase walking activity to promote collateral
circulation and improve blood supply to extremity.

c- Teach patient to avoid crossing legs or keeping legs in a dependent

position to avoid constriction of veins

d- Refer patients who smoke to smoking cessation program because

continued smoking will significantly increase risks for further
damage.

Evaluation: (for the two priority diagnoses)

1- Goal met , evidence by there is no signs and symptoms of hypovolemia (normal BP 115\70 ,HB
and RBC's within normal range at the end of my shift .
2- Goal met , evidence by showing signs and symptoms of good tissue perfusion (warm
extremities , present peripheral pulse ,and o2 sat level within normal(95%) ) ,At the end of my shift .